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Introduction • The term Nursing Process was first used/ mentioned by Lydia Hall, a nursing theorist, in 1955 wherein she introduced 3 STEPs: observation, administration of care and validation. • Since then, nursing process continue to evolve: it used to be a 3-step process, then a 4-step process (APIE), then a 5-step (ADPIE), now a 6-step process(ADOPIE) Assessment, Diagnosis, Outcome, Identification, Planning, Implementaton and Evaluation. Definition • Is a systematic, organized method of planning, and providing quality and individualized nursing care. • It is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse and the client to determine the need for nursing care, to plan and implement the care and evaluate the result.
It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care.
Goal-oriented – nurse make her objective based on client’s health needs. Remember: Goals and plan of care should be base according to clients problems/needs NOT according to your own problem as the nurse. Organized/Systematic – the nursing process is composed of 6 sequential and interrelated steps and these 6 phases follow a logical sequence. Humanistic care • Plan to care is developed and implemented taking into consideration the unique needs of the individual client. • plan of care therefore is individualized (no 2 person has the same health needs even with same health condition/illness)
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in providing care, it involves respect of human dignity Efficient – plan of case is relevant/ related to the needs of the client thereby promoting client satisfaction and progress. Effective – in planning care, utilized resources wisely (staff, time, money/cost)
Aside from GOSH, other characteristic of Nursing Process: • Cyclic and Dynamic in nature – data from each phase provides the input into the next phase so that is becomes a sequence of events (cycle) that are constantly changing (dynamic) base on client’s health status. • Involves skill in Decision-making – nurse makes important decisions related to client care, she choose the best action/steps to meet a desired goal or to solve a problem. She must make decisions whenever several choices or options are available.
Purpose: To establish a data base (all the information about the client): • • • • nursing health history physical assessment the physician’s history & physical examination results of laboratory & diagnostic tests material from other health personnel FOUR Types of Assessment 1. breathing status & circulation after a cardiac arrest. Outcome Identification Planning Implementation Evaluation • • Assessment . To provide nursing interventions to meet those needs. 4. related experiences. Assessment 2. 3. It includes the client’s perceived needs. 5. 2. .• Uses Critical Thinking skills – the nurse may encounter new ideas or less-than-routine or nonordinary situations where decisions must be made using critical thinking. 2. validation and communication of client data as compared to what is standard/norm. health practices. values and lifestyles. health problems. Steps/Phases of the Nursing Process: 1. To establish a plan of care to meet identified needs. effective and efficient nursing care.First Step in the Nursing Process It is systematic and continuous collection. Purpose of Nursing Process: 1. his Actual/Present and potential/possible health problems or needs. Diagnosis 3. To provide an individualized. Ex: problem on urination-assess on fluid intake & urine output hourly Emergency assessment – rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems. 4. To identify a client’s health status. Time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the client’s current status to baseline data previously obtained. Initial assessment – assessment performed within a specified time on admission o Ex: nursing admission assessment Problem-focused assessment – use to determine status of a specific problem identified in an earlier assessment o 3. holistic. 6. Ex: assessment of a client’s airway. o 4.
psychological. Example: pain. or to provide support or counseling. spiritual factors that may affect client’s health status • • includes past health history of client (allergies. Example: pallor. Observation . o it is used while taking the nursing history of a client 2. other health professionals are considered subjective data. nausea. socio-cultural. religious practices. BP=150/100. use of folk healing methods) includes current/present problems of client (pain. ringing of ears/Tinnitus Objective data o o o also referred to as Sign/Overt data Those that can be detected observed or measured/tested using accepted standard or norm. Collection of data Validation of data Organization of data Analyzing of data Recording/documentation of data Assessment • Observation of the patient + Interview of patient. evaluate change. Interview o A planned. 2. 5.Activities 1. purposeful conversation/communication with the client to get information. dizziness. 3. identify problems. yellow discoloration of skin Methods of Data Collection 1. emotion. chronic diseases. 4. Information from the client’s point of view or are described by the person experiencing it. Information supplied by family members. to teach. sleep pattern. significant others. diaphoresis. past surgeries. Subjective data o also referred to as Symptom/Covert data o o o 2. meds or treatment the client is taking now) Types of Data 1. family & SO + examination of the patient + Review of medical record Collection of data • gathering of information about the client • includes physical.
clinics. diets. religion. hypertension. experiences with illness. other members of health team. ensure that data collection is complete ensure that objective and subjective data agree obtain additional data that may have been overlooked . o o o o o o o o History of present Illness – includes: usual health status. physical examination techniques (IPPA). 3. sleep or rest patterns. martial status. Purposes of data validation 1. Examination o o Systematic data collection to detect health problems using unit of measurements. ethnic and educational background. 3. activities of daily living. Secondary source – data gathered from client’s family members. significant others. Validation of Data • The act of “double-checking” or verifying data to confirm that it is accurate and complete. home and neighborhood conditions. recreation or hobbies. sex. client’s medical records/chart. 3. health centers. cancer. address. Primary source – data directly gathered from the client using interview and physical examination. obtain a Nursing Health History . o Reason for visit/Chief complaint – primary reason why client seek consultation or hospitalization. chronological story. Family History – reveals risk factors for certain disease diseases (Diabetes. Components of a Nursing Health History: o Biographic data – name. 2. family doctors. Past Health History – includes all previous immunizations. family history. Cephalocaudal approach – head-to-toe assessment Body System approach – examine all the body system Review of System approach – examine only particular area affected Source of data 1. occupation. disability assessment. interpretation of laboratory results. Social data – include family relationships.o Use to gather data by using the 5 senses and instruments. mental illness). and related care literature/journals. should be conducted systematically: 1. 2. economic status. 2. Review of systems – review of all health problems by body systems Lifestyle – include personal habits. Pattern of health care – includes all health care resources: hospitals. o In the Assessment Phase. age. Psychological data – information about the client’s emotional state.a structured interview designed to collect specific data and to obtain a detailed health record of a client.
2. Cues avoid jumping to conclusion differentiate cues and inferences • Subjective or objective data observed by the nurse. Body System Model 3. 6. Example: o o Red swollen wound = infected wound Dry skin = dehydrated Organization of Data Uses a written or computerized format that organizes assessment data systematically. hear. Standard/norm are generally accepted measurements. smell or measure. 4. Value-belief pattern Analyze data • Compare data against standard and identify significant cues. Inferences • • The nurse interpretation or conclusion based on the cues. pattern: o Ex: Normal vital signs. 8. 7. feel. Gordon’s Functional Health Patterns: Gordon’s Functional Health Patterns 1. normal growth and development pattern Communicate/Record/Document Data • nurse records all data collected about the client’s health status . Maslow’s basic needs 2. 9. 5. it is what the client says. Elimination pattern Activity-exercise pattern Sleep-rest pattern Cognitive-perceptual pattern Self-perception-concept pattern Role-relationship pattern Sexuality-reproductive pattern 10.4. standard Weight and Height. Nutritional-metabolic pattern 3. 5. 1. normal laboratory/diagnostic values. or what the nurse can see. model. Coping-stress tolerance pattern 11. Health perception-health management pattern.
It states a clear and concise health problem. to reduce. 2. 3.Second Step in the Nursing Process Definition • • Is the 2nd step of the nursing process. . Data Analysis 2. Is the problem statement that the nurse makes regarding a client’s condition which she uses to communicate professionally. Problem Identification 3. • • o o Analysis – separation into components or the breaking down of the whole into its parts. It is derived from existing evidences about the client. restating in other words what client says might change its original meaning. A statement that describes a client’s actual or potential health problems that a nurse can identify and for which she can order nursing interventions to maintain the health status. It is potentially amenable to nursing therapy. To diagnose in nursing It means to analyze assessment information and derive meaning from this analysis. the process of reasoning or the clinical act of identifying problems Purpose • • • To identify health care needs and prepare a Nursing Diagnosis. eliminate or prevent alterations/changes.• • data are recorded in a factual manner not as interpreted by the nurse Record subjective data in client’s word. It uses the critical-thinking skills analysis and synthesis in order to identify client strengths & health problems that can be resolves/prevented by collaborative and independent nursing interventions. Is a statement of client’s potential or actual alterations/changes in his health status. Diagnosis . Formulation of Nursing Diagnosis Characteristics of Nursing Diagnosis 1. Synthesis – the putting together of parts into whole Three Activities in Diagnosing: 1. Nursing Diagnosis • • • Is a statement of a client’s potential or actual health problem resulting from analysis of data.
Potential Nursing diagnosis – one in which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it. • • • • • • • Constipation r/t long term use of laxative. . Risk Nursing diagnosis – is a clinical judgment that a problem does not exist.4. It is the basis for planning and carrying out nursing care. • Risk for interrupted family processes r/t mother’s illness & unavailability to provide child care. Examples: • Possible nutritional deficit • Possible low self-esteem r/t loss job • Possible altered thought processes r/t unfamiliar surroundings 3. Anxiety r/t difficulty of breathing & concerns over work 2. • Disturbed Sleep Pattern r/t cough. but the presence of RISK FACTORS is indicates that a problem is only is likely to develop unless nurse intervene or do something about it. • • Risk for Constipation r/t inactivity and insufficient fluid intake Risk for infection r/t compromised immune system. 3. Examples: • Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in diabetes. Components of A nursing diagnosis (PES or PE) 1. or the causative factors are unknown but a problem is only considered possible to occur. Actual Nursing Diagnosis – a client problem that is present at the time of the nursing assessment. Examples: • Imbalanced Nutrition: Less than body requirements r/t decreased appetite nausea. • Types of Nursing Diagnosis 1. 2. therefore no S/S are present. Ineffective airway clearance r/t to viscous secretions Noncompliance (Medication) r/t unknown etiology Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis Acute Pain (Chest) r/t cough 2nrdary to pneumonia Activity Intolerance r/t general weakness. fever and pain. It is based on the presence of signs and symptoms. No subjective or objective cues are present therefore the factors that cause the client to be more vulnerable to the problem are the etiology of a risk nursing diagnosis. Problem statement/diagnostic label/definition = P Etiology/related factors/causes = E Defining characteristics/signs and symptoms = S *Therefore may be written as 2-Part or a 3-Part statement.
flush skin. degree. health risks.2°C Respiratory Rate (RR) = 35 P = 96. Nursing Diagnosis • Hyperthermia [related to (r/t)] environmental condition AMB T = 39°C. Possible nursing diagnosis = Problem + Etiology Qualifiers – words added to the diagnostic label/problem statement to gain additional meaning. Cluster or group data 3. damaged. incomplete • “impaired” – made worse. warm to touch. amount. 4.• Risk for injury r/t decreased vision after cataract surgery. quality. 5. “(“I suddenly felt cold. masakit ang ulo at mainit ang pakiramdam pagkatapos kong maglaba sa kabilang kanto. 35 years of laundry woman seeks consultation at the Philippine General Hospital due to fever 2 days prior to admission PTA. strengths Formulate Nursing Diagnosis – prioritize nursing diagnosis based on what problem endangers the client’s life Situation: Functional Health Pattern – Activity/Exercise • Anna. Situation: Functional Health Pattern = Nutritional/Metabolic 1. She has 3 children she walks off to school everyday before she goes to work Vital Signs • Temperature (T) =39. States. 4. Data analysis after comparing with standards Identify gaps and inconsistencies in data Determine the client’s health problems. weakened. with flush skin and warm to touch. Formula in writing nursing diagnosis (PES or PE) 1. • “deficient” . headache and warm after I done laundry”). teary eyed and dry lip and mucous membrane. deteriorated • • “decreased” – lesser in size. = Problem + Etiology + S/S 2. 3. She verbalizes: “Bigla na lang ako giniginaw. Actual nursing diagnosis = Patient problem + Etiology – replace the (+) symbol with the words “RELATED TO” abbreviated as r/t. 6.inadequate in amount. degree “ineffective” – not producing the desired effect Activities during diagnosis: 1. “No appetite since having cough” Has not eaten today. teary eyed and with dry lips and mucous membrane. last fluids at noon today Has lost 8 lbs in past 2 weeks Nauseated x 2 days Nursing Diagnosis . reduced. insufficient. 2. Compare data against standards 2. Risk Nursing diagnosis = Problem + Risk Factors 3.
Example of verbs used in client goals: o Calculate . will be back next week. • Are written to indicate a desired state. Establish client’s goals and outcome criteria Client Goal • Is an educated guess made as a broad statement about what the client’s state or condition will be AFTER the nursing intervention is carried out. Purposes 1. They contain action word/verb and a qualifier that indicate the level of performance that needs to be achieved. “I can’t breath” Facial muscles tense. 5. Difficulty sleeping because of cough 2. Report pain on chest when coughing Nursing Diagnosis • Disturbed Sleep Pattern r/t a disease process. Outcome Identification Definition • Refers to formulating and documenting measurable. 2. 4. To provide individualized care 2. Nursing Diagnosis • Anxiety r/t difficulty of breathing and concerns over parenting roles.• Imbalanced Nutrition: Less than body Requirements r/t decreased appetite and nausea 2ndary to disease process/cough Situation: Functional Health Pattern = Activity/Exercise 1. To promote client participation 3. realistic and client-focused goals that will provide the basis for evaluating nursing diagnosis. States. 4. Acute Pain (chest) r/t pathologic condition 2ndary to pneumonia Situation: Functional Health Pattern = Coping/Stress 1. orthopnea and pain. Anxious State. trembling Expresses concern and worry over leaving daughter with neighbors Husband out of town. To plan care that is realistic and measurable To allow involvement of support people Activities during Outcome Identification 1. “Can’t breath lying down” 3. 3.
o o o o o o o o o o o o o o o o o o o o o o o o o o • Classify Communicate Compare Define Demonstrate Describe Construct Contrast Distinguish Draw Explain Express Identify List Name Maintain Perform Particular Practice Recall Recite Record State Use Verbalize Ambulates *a Qualifier is a description of the parameter or criteria for achieving the goal. Identifies actual & risk environmental hazards. . Example: o o o Ambulates safely with one-person assistance. Demonstrates signs of sufficient rest before Surgery.
Goals may be short term or long term • • • Short Term Goal (STG) – can be met in a short period (within days or less than a week) Long Term Goal (LTG) – requires more time (several weeks or months) Outcome Criteria – are specific. • The client demonstrates safety practices when dressing and doing personal hygiene. Goal – The client will mobilize lung secretions. the client uses call light system for assistance when needs to use the bathroom. They are written in a manner that they answer the questions: who. Possible Outcome Criteria: • After teaching session. vibration and postural drainage before discharge Planning Definition . Possible Outcome Criteria: • Immediately after instruction by the nurse. Goal – The client will demonstrate safety habits when performing activities of daily living. 2. the client demonstrates proper coughing techniques. 12 hours after nurse’s instruction about home safety. installation of hand rails in hallway. non-skid slippers when transferring to chair or getting out of bed. the client verbalizes decreased anxiety. Possible Outcome Criteria: • The client discusses fears & concern regarding surgical procedure after client teaching. measurable. Goal – The client will report a decreased anxiety level regarding Surgery. • • The client uses over-the-bed lights. what actions. • After client teaching. Therefore the characteristic of well-stared outcome criteria are: • S = smart M = measurement A = attainable R = realistic T = time-framed Example of Goals and Outcome Criteria 1. realistic statements goal attainment. • The client drinks at least 6 glasses of water per day while in the hospital. The client identifies modification for home safety (removal of throw pillows. • The caregiver or significant other demonstrates proper technique of chest physiotherapy including percussion. better lighting of hallway and stairway). how well and when. 3. • The client identifies a support system and strategies to use to reduce stress and anxiety related to the surgical experience. under what circumstance.
Plan nursing interventions/nursing orders to direct activities to be carried out in the implementation phase. and considered the most important among several items. Actual problems take precedence over potential concerns. breathing. 8. Life-threatening situations should be given highest priority. 2. Guideline for setting priorities: 1. 2. under a physician’s supervision. and drainage tube. Nursing interventions • Any treatment. Establish/Set priorities • Priority – is something that takes precedence in position. circulation) Use Maslow’s hierarchy of needs. 1. Use the principle of ABC’s (airway. materials. Clients with unstable condition should be given priority over those with stable conditions. Attend to client before equipment. To allow for delegation of specific activities. Purpose • • • • To determine the goals of care and the course of actions to be undertaken during the implementation phase. the client and his family should be involve in planning. 7. To be effective. Dependent Nursing Intervention – those activities carried out on the order of a physician. resolve or control a problem. 6. assist with activities of daily living. 5. Ex: assess the client before checking IV fluids. or promote optimum health and independence. Ex: attend to client who requires dressing change for postop wound before attending to client who requires health teachings & is ready to be discharged late in the afternoon. based upon clinical judgment and knowledge. • They maybe independent. urinary catheter. that a nurse performs to enhance client outcomes. 3. Ex: attend to client with fever before attending to client who is scheduled for physical therapy in the afternoon. 4. o o Independent Nursing Intervention – those activities that the nurse is licensed to initiate as a result of the nurse’s own knowledge and skills. or according to specific routines. • They are used to monitor health status.• Involves determining before and the strategies or course of actions to be taken before implementation of nursing care. To focus charting requirements. To promote continuity of care. Consider the amount of time. It is a decision making process that ranks the order of nursing diagnosis in terms of importance to the client. Consider something that is very important to the client. . equipment required to care for clients. prevent. dependent and independent/collaborative activities that nurses carry out to provide client care.
partially met or completely unmet. decision-making and teaching. 4. relevant documentation should be done. 4. Dependent or collaborative measures. 4. Nursing interventions must be specifically designed to meet the identified goal. Requirements of Implementation 1. Reassessing – to ensure prompt attention to emerging problems. which is the justification or reason for carrying out the intervention. Perform nursing interventions – these may be independent. Activities 1. Write a Nursing Care Plan Nursing Care Plan (NCP) • A written summary of the care that a client is to receive. It is s step-by-step process as evidence by: 1. Sufficient data are collected to substantiate nursing diagnosis. 3. 6. 3. Record actions – to complete nursing interventions. Evaluation must address whether each goal was completely met. . Communication skills – use of verbal and non-verbal communication to carry out planned nursing interventions. Technical skills – to carry out treatment and procedures.o Interdependent/Collaborative – those activities the nurse carries out in collaboration or in relation with other members of the health care team. Knowledge – include intellectual skills like problem-solving. Purpose • To carry out planned nursing interventions to help the client attain goals and achieve optimal level of health. • It is the “blueprint” of the nursing process. Remember: Something that is NOT written is considered as NOT done at all. Outcome criteria must be identified for each goal. At least one goal must be stated for each nursing diagnosis. 3. Therapeutic use of self – is being willing and being able to care. Implementation Definition • Is putting the nursing care plan into action. 5. 2. Set priorities – to determine the order in which nursing interventions are carried out. 3. Each intervention should be supported by a scientific rationale. 2. 2. • • It is nursing centered in that the nurse remains in the scope of nursing practice domain in treating human responses to actual or potential health problems.
The four possible judgments that may be made are as follows: o o o o 4. Purpose: • To appraise the extent to which goals and outcome criteria of nursing care have been achieved. Analyze the reasons for the outcomes. Collect data about the client’s response. 3. 2. The goal was completely unmet. 5. Modify plan of care as needed. New problems & nursing diagnosis have developed.Evaluation Definition • Is assessment the client’s response to nursing interventions and then comparing that response to predetermined standards or outcome criteria. The goal was partially met. Activities: 1. Compare the client’s response to goals and outcome criteria. The goal was completely met. .
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